NURS 120: Introduction to Medical-Surgical Nursing - Exam 1
Comprehensive Assessment 2026 |WCU
1. A patient is admitted with a pH of 7.28, PaCO2 of 52 mmHg, and HCO3- of 24
mEq/L. Which acid-base imbalance is the patient experiencing?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
Answer: C
Rationale: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mmHg with a normal
bicarbonate (HCO3-) indicates that the primary cause is respiratory, resulting in
Respiratory Acidosis.
2. Which clinical manifestation should the nurse prioritize when assessing a
patient with a potassium level of 6.2 mEq/L?
A. Prominent U-waves on the EKG
B. Hypoactive bowel sounds
C. Tall, peaked T-waves on the EKG
D. Generalized muscle weakness
Answer: C
Rationale: Hyperkalemia (K+ > 5.0) causes cardiac dysrhythmias; tall, peaked T-waves are
a hallmark sign. U-waves are seen in hypokalemia.
,3. A postoperative patient develops a sudden protrusion of organs through the
surgical incision. What is the immediate nursing action?
A. Push the organs back into the abdominal cavity
B. Cover the area with sterile saline-soaked dressings
C. Apply a dry sterile dressing tightly
D. Call the physician while leaving the patient alone
Answer: B
Rationale: Evisceration is a medical emergency. The nurse must cover the protruding
organs with sterile, moist saline dressings to prevent drying and infection while calling for
help.
4. Which electrolyte imbalance is indicated by a positive Chvostek’s sign and
Trousseau’s sign?
A. Hypercalcemia
B. Hypocalcemia
C. Hyperkalemia
D. Hypokalemia
Answer: B
Rationale: Hypocalcemia increases neuromuscular irritability. Chvostek’s (facial
twitching) and Trousseau’s (carpal spasm with BP cuff) are classic signs.
5. What is the primary goal of the ‘Time-Out’ procedure performed in the
operating room?
A. To verify the correct patient, site, and procedure
B. To ensure the surgeon has had enough rest
C. To count the number of sponges before closing
D. To obtain informed consent from the patient
Answer: A
, Rationale: The Universal Protocol (Time-Out) is used immediately before the procedure
starts to prevent wrong-site, wrong-procedure, and wrong-person surgery.
6. A patient with Type 1 Diabetes is found unconscious and clammy. The nurse
suspects hypoglycemia. After checking the blood glucose (40 mg/dL), what is the
first action?
A. Administer 15g of oral glucose gel
B. Administer 10 units of Regular Insulin
C. Administer 1 mg of Glucagon IM or SubQ
D. Provide 4 oz of orange juice
Answer: C
Rationale: If a patient is unconscious, they cannot safely swallow. Glucagon IM/SubQ or IV
Dextrose is required to treat severe hypoglycemia.
7. Which IV fluid is considered hypotonic?
A. 0.45% Normal Saline
B. Lactated Ringer’s
C. 0.9% Normal Saline
D. 5% Dextrose in 0.9% Saline
Answer: A
Rationale: 0.45% Normal Saline (half-normal) is hypotonic, used to treat cellular
dehydration by moving water into cells.
Comprehensive Assessment 2026 |WCU
1. A patient is admitted with a pH of 7.28, PaCO2 of 52 mmHg, and HCO3- of 24
mEq/L. Which acid-base imbalance is the patient experiencing?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
Answer: C
Rationale: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mmHg with a normal
bicarbonate (HCO3-) indicates that the primary cause is respiratory, resulting in
Respiratory Acidosis.
2. Which clinical manifestation should the nurse prioritize when assessing a
patient with a potassium level of 6.2 mEq/L?
A. Prominent U-waves on the EKG
B. Hypoactive bowel sounds
C. Tall, peaked T-waves on the EKG
D. Generalized muscle weakness
Answer: C
Rationale: Hyperkalemia (K+ > 5.0) causes cardiac dysrhythmias; tall, peaked T-waves are
a hallmark sign. U-waves are seen in hypokalemia.
,3. A postoperative patient develops a sudden protrusion of organs through the
surgical incision. What is the immediate nursing action?
A. Push the organs back into the abdominal cavity
B. Cover the area with sterile saline-soaked dressings
C. Apply a dry sterile dressing tightly
D. Call the physician while leaving the patient alone
Answer: B
Rationale: Evisceration is a medical emergency. The nurse must cover the protruding
organs with sterile, moist saline dressings to prevent drying and infection while calling for
help.
4. Which electrolyte imbalance is indicated by a positive Chvostek’s sign and
Trousseau’s sign?
A. Hypercalcemia
B. Hypocalcemia
C. Hyperkalemia
D. Hypokalemia
Answer: B
Rationale: Hypocalcemia increases neuromuscular irritability. Chvostek’s (facial
twitching) and Trousseau’s (carpal spasm with BP cuff) are classic signs.
5. What is the primary goal of the ‘Time-Out’ procedure performed in the
operating room?
A. To verify the correct patient, site, and procedure
B. To ensure the surgeon has had enough rest
C. To count the number of sponges before closing
D. To obtain informed consent from the patient
Answer: A
, Rationale: The Universal Protocol (Time-Out) is used immediately before the procedure
starts to prevent wrong-site, wrong-procedure, and wrong-person surgery.
6. A patient with Type 1 Diabetes is found unconscious and clammy. The nurse
suspects hypoglycemia. After checking the blood glucose (40 mg/dL), what is the
first action?
A. Administer 15g of oral glucose gel
B. Administer 10 units of Regular Insulin
C. Administer 1 mg of Glucagon IM or SubQ
D. Provide 4 oz of orange juice
Answer: C
Rationale: If a patient is unconscious, they cannot safely swallow. Glucagon IM/SubQ or IV
Dextrose is required to treat severe hypoglycemia.
7. Which IV fluid is considered hypotonic?
A. 0.45% Normal Saline
B. Lactated Ringer’s
C. 0.9% Normal Saline
D. 5% Dextrose in 0.9% Saline
Answer: A
Rationale: 0.45% Normal Saline (half-normal) is hypotonic, used to treat cellular
dehydration by moving water into cells.
